VA Healthcare - VISN 4 (VISN 4)

Issue: A DD214 belonging to an employee was returned to the wrong employee however on the back side of the DD214 was the name and SSN of the employee who received it. Both employees saw each other's information. Update: 02/07/12:Both employees…

Outcome: Supervisor and facility IRT made aware of incident. Employee was re-educated in proper handling of paper documents and asked to re-take HIPAA and Privacy training.…

Issue: Veteran A requested and was provided an imaging CD to hand carry to his civilian provider. Veteran A reports that at his appointment with his civilian provider, he was told the data on the CD was not his. Veteran A…

Outcome: Service Line Mgt has re-educated the employee about handling PII. Action has been taken to remove the employee from the designated position.…

Issue: On or about 01/28/12, Veteran A received in the mail VA Form 10-5345 (Individuals' Request for a Copy of Their Own Health Information). The form contained Veteran B's full name, SSN, date of birth and home address. Veteran A returned…

Outcome: Corrective action has been taken to improve the ROI process of mailing VA Forms 10-5345 and 10-5345a. Please see activity comments for further details.…

Issue: A patient had an appointment at one of our facilities outpatient clinics. The patient has a medical diagnoses listed under U.S. code 7332. Staff thought the patient may have been under the influence of a substance. Staff called the local…

Outcome: The Privacy Officers have scheduled U.S. C. 7332 training to various staff throughout the Butler VA Healthcare System to make them more aware of the regulations. This will hopefully eliminate or at least reduce information being released that should not…

Issue: Veteran A requested a copy of some of his medical record information. Veteran B received Veteran A's medical information in the mail. Veteran B opened up the envelope with medical records inside, noticed the records were not his medical records,…

Outcome: Employee was reminded on the importance of ensuring accuracy when mailing out personal identifiable information.

Issue: A patient signed a release for a VA provider to sign and release a medical assessment for the State Department of Public Welfare. A diagnosis listed under the U.S.C. code 7332 was released without proper authorization. All other information was…

Outcome: Retraining of staff has already taken place. The Privacy Officer is meeting with the group involved with the release of this U.S.C. code 7332 information. The Privacy Officers are training them in the correct procedure of releasing this type of…

Issue: A VA employee found a transportation list dated 01/25/12 in the garbage can outside of the VA Administration Building. These documents originated as a VistA email list of 33 Veterans for transportation today. This list includes full names, last 4…

Outcome: Facilities Management reports the following corrective actions will be implemented: 1. Redaction of the SSN from transportation lists before distributing assignments to the motor vehicle operators. 2. Each motor vehicle operator will be contacted and reminded to shred the transportation…

Issue: Veteran A called the Release of Information (ROI) office to report that he recived Veteran B's medical records via UPS. Veteran A is coming into the healthcare facility for an appointment tommorrow and will bring in the records and return…

Outcome: ROI Supervisor reducated staff about proper quality assurance checks before sending out medical records. CM letter sent to affected Veteran…

Issue: The Pharmacy reported an incident that was just reported where the USPS delivered a medication package to the wrong Veteran.The Veteran who should have got the package lives on the same street that the other Veteran lives on who received…

Outcome: Mis-mailed information is in the process of being recovered. The error was caused by the USPS.…

Issue: A Community Based Outpatient Clinic (CBOC) contract employee reported that Veteran A received Veteran B's x-ray report in error. The x-ray report was stuck to Veteran A's lab result. Veteran A received Veteran B's name, address, full SSN and diagnosis…

Outcome: The CBOC staff have been reeducated about better QA processes to check each document and verify the correct name before placing in an envelope.The CBOC clinic manager will procure Softwork (fingertip moistener) to assist staff when sorting documents.